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"Seeing the Big Picture in Health Care" By Julia Vermeulen

While training a group of health career interns from the University of Arizona last Saturday, a colleague and I introduced their semester-long project by taking a look at a hypothetical patient named Jason.

Jason, an 8-year-old boy, is in the hospital because he has an infected cut on his leg. We asked the students-- many of them aspiring doctors and nurses-- to think about how they might treat Jason knowing that information. Prescribe antibiotics and send him home, most of them said.

But what if we go deeper? How did Jason get that cut? When the students asked more questions, they learned that Jason fell on some sharp, jagged steel while playing in a junkyard by himself. It turns out there were no other safe places to play in his neighborhood and nobody available to supervise him. His parents cannot afford to live somewhere safer because his dad has not been able to find work and his mom is sick. She has been avoiding aggressive treatment because she does not have health insurance to cover it.

What if our healthcare system had helped Jason and his family earlier, perhaps when his mother’s illness first got diagnosed? His mother could have been assisted with finding affordable health insurance on the Marketplace, signed up for AHCCCS (Arizona’s version of Medicaid), or offered treatment through other initiatives, programs, and sliding fee scales. Jason’s father could connect with  job counseling and education opportunities, and affordable afterschool and childcare programs could have been identified for little Jason. With these resources, maybe he would not have been playing in the junkyard in the first place.

These factors-- neighborhood, access to insurance, employment status, education, and childcare availability-- are just a few of what are called “social and physical determinants of health,” a fancy term for what essentially means one’s social and physical environment, both of which play a huge role in our health and the behaviors that influence our health. Focusing on these determinants makes plain good sense-- for individuals, for our overworked medical providers, and for fixing what is currently the most expensive and least effective health care system compared with similar industrialized nations.[1]

El Rio Community Health Center, where I have spent the past two and a half months, employs an entire department of people--around a dozen staff members-- who work closely with medical providers and community partners to address all of the needs of our patients. These Community Health Advisors have a close relationship with the community we serve, allowing them to better connect patients with any resources they might need, from diapers to prescription assistance to home repairs for the elderly, and conduct community outreach and health education programs to ensure that people are informed about how to keep themselves and their families healthy. Along with health centers across the country who employ Community Health Advisors (also known as Community Health Workers or Patient Advocates), El Rio has recognized that addressing these seemingly non-medically relevant needs is vital to keeping the community healthy and preventing costly interventions down the road.

One of my projects this year is figuring out how to better screen patients when they walk in the door, even ones who do not come directly to the Community Health Advisors with questions about resources, and then pilot ways to connect them with those resources more efficiently, which would allow the Community Health Advisors to spend their time assisting with more complex needs. El Rio is part of a long history of community participation in local health promotion, so harnessing the talents and passions of community members will be a vital part of this effort. I feel very lucky to be involved and look forward to the rest of this year! 


[1] K. Davis, K. Stremikis, C. Schoen, and D. Squires, Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally, The Commonwealth Fund, June 2014. 

Published on February 22, 2016 by Spencer Brown.

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